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Nasca V, Prinzi N, Coppa J, Prisciandaro M, Oldani S, Ghelardi F, Conca E, Capone I, Busico A, Perrone F, Tamborini E, Sabella G, Greco G, Greco FG, Tafuto S, Procopio G, Morano F, Niger M, Maccauro M, Milione M, de Braud F, Pietrantonio F, Pusceddu S. Sunitinib for the treatment of patients with advanced pheochromocytomas or paragangliomas: The phase 2 non-randomized SUTNET clinical trial. Eur J Cancer 2024; 209:114276. [PMID: 39128186 DOI: 10.1016/j.ejca.2024.114276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 07/30/2024] [Accepted: 08/02/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND Metastatic Pheochromocytomas and paragangliomas (PPGLs) are rare neuroendocrine tumors characterized by high morbidity and limited systemic treatment options, mainly based on radiometabolic treatments or chemotherapy. Based on the preclinical rationale that PGGLs carcinogenesis relies on angiogenesis, treatment with tyrosine kinase inhibitors (TKI) may represent another viable therapeutic option. METHODS We conducted a prospective phase II study in patients with metastatic or unresectable PGGLs. Patients received sunitinib (50 mg daily for 4 weeks, followed by a 2-week rest period) until progressive disease (PD), unacceptable toxicity or consent withdrawal. The primary endpoint was 12-month progression-free survival (PFS) rate; secondary endpoints were safety overall response rate (ORR) according to RECIST 1.1 criteria and overall survival (OS). EudraCT Number: 2011-002632-99. RESULTS Fifty patients were included. At a median follow-up of 71.7 months (IQR 35.4-100.1), the 1 year-PFS rate was 53.4 % (95 %CI 41.1-69.3) and median PFS was 14.1 months (95 % CI 8.9-25.7). ORR was 15.6 %, the median OS was 49.4 months (95 %CI 21.2-NA), and grade 3 or higher treatment-related adverse events were reported in 34 % patients. No significant correlation was found between specific genetic alterations or genomic clusters and sunitinib efficacy. CONCLUSION Sunitinib is an active drug in patients with advanced PGGLs, capable of inducing prolonged disease control with a manageable toxicity profile.
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Affiliation(s)
- Vincenzo Nasca
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Natalie Prinzi
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Jorgelina Coppa
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Michele Prisciandaro
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Simone Oldani
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Filippo Ghelardi
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Elena Conca
- Diagnostic Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Iolanda Capone
- Diagnostic Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Adele Busico
- Diagnostic Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Federica Perrone
- Diagnostic Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elena Tamborini
- Diagnostic Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giovanna Sabella
- Diagnostic Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giorgio Greco
- Radiology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Salvatore Tafuto
- Sarcoma and Rare Tumors Unit, Istituto Nazionale Tumori IRCCS, Fondazione G. Pascale, Naples, Italy; ENETs Center of Excellence, Naples, Italy
| | - Giuseppe Procopio
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Federica Morano
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Monica Niger
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Marco Maccauro
- Department of Nuclear Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, ENETS Center of Excellence, Milan, Italy
| | - Massimo Milione
- Diagnostic Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Filippo de Braud
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy; University of Milan, Milan, Italy
| | - Filippo Pietrantonio
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Sara Pusceddu
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy; ENETS Center of Excellence, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy.
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Prinzi N, Corti F, Torchio M, Niger M, Antista M, Pagani F, Beninato T, Pulice I, Rossi RE, Coppa J, Cascella T, Giacomelli L, Di Bartolomeo M, Milione M, de Braud F, Pusceddu S. Metastatic pheochromocytomas and paragangliomas: where are we? TUMORI JOURNAL 2022; 108:526-540. [PMID: 35593402 DOI: 10.1177/03008916221078621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pheochromocytomas and paragangliomas (PPGLs) can metastasize in approximately 15-20% of cases. This review discusses the available evidence on the biology and treatment of metastatic PPGLs. Chemotherapy is the first-line treatment option for this evolving and symptomatic disease. In patients with high MIBG uptake and positive PETGa-68, radiometabolic treatment may be considered. The efficacy of sunitinib has been shown in observational studies, and pembrolizumab has been evaluated in phase II clinical studies, while other agents investigated in this setting are anti-angiogenic drugs cabozantinib, dovitinib, axitinib and lenvatinib. As these agents' efficacy and safety data, alone or in combination, are scant and based on few treated patients, enrollment in clinical trials is mandatory. Future therapeutic options may be represented by DNA repair system inhibitors (such as olaparib), HIF2 inhibitors and immunotherapy.
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Affiliation(s)
- Natalie Prinzi
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Francesca Corti
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Martina Torchio
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Monica Niger
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Maria Antista
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Filippo Pagani
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Teresa Beninato
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Iolanda Pulice
- Clinical Trial Center, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Roberta Elisa Rossi
- Gastro-intestinal Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Pathophysiology and Organ Transplant, Università degli Studi di Milano, Milan, Italy
| | - Jorgelina Coppa
- Gastro-intestinal Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Tommaso Cascella
- Radiology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Maria Di Bartolomeo
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
| | - Massimo Milione
- Diagnostic Pathology and Laboratory Medicine Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Filippo de Braud
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy.,Oncology and Hemato-Oncology Department, Università degli Studi di Milano, Milan, Italy
| | - Sara Pusceddu
- Department of Medical Oncology, Fondazione IRCCS Istituto Tumori Milano, Milan, Italy
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Hassan Nelson L, Fuentes-Bayne H, Yin J, Asmus E, Ryder M, Morris JC, Hilger CR, Bible KC, Chintakuntlawar AV, Rao SN. Lenvatinib as a Therapeutic Option in Unresectable Metastatic Pheochromocytoma and Paragangliomas. J Endocr Soc 2022; 6:bvac044. [PMID: 35402763 PMCID: PMC8989149 DOI: 10.1210/jendso/bvac044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Context
Metastatic pheochromocytomas and paragangliomas (mPPGL) are rare vascular neuroendocrine tumors that highly express vascular growth factors. Systemic treatment options in cases of unresectable multi-site disease are limited. Multikinase inhibitors, that inhibit angiogenesis, such as lenvatinib, have proven effective in several other malignancies, and may be a viable option for mPPGL.
Objective
To evaluate the efficacy of lenvatinib as salvage therapy in mPPGLs.
Design
Retrospective analysis of mPPGL patients who received lenvatinib from 2015-2020.
Setting
Tertiary referral center
Patients
Patients ≥ 18 years with mPPGL who were treated with lenvatinib were included.
Intervention
Patients were started on lenvatinib 20 mg daily and dose was adjusted according to tolerance or disease progression.
Results
11 patients were included. Median treatment duration was 14.7 months (95% CI: 2.3-NE). Treatment was discontinued due to disease progression, adverse events, or death. Overall survival at 12 months was 80.8% (95% CI: 42.3-94.9%) but its median was not reached. Median progression free survival was 14.7 months (CI 95%: 1.7-NE). Among the 8 patients with measurable disease, overall response rate was 63% as 5/8 experienced a partial response and 3/8 had stable disease. Worsening hypertension and anemia were the most common adverse events (AE).
Conclusions
Lenvatinib may be a viable treatment option for mPPGL, though at the potential risk of worsening hypertension. Larger, multi-center studies are needed to better characterize treatment efficacy.
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Affiliation(s)
| | | | - Jun Yin
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Erik Asmus
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Mabel Ryder
- Division of Medical Oncology, Mayo Clinic, Rochester, MN
| | - John C Morris
- Division of Medical Oncology, Mayo Clinic, Rochester, MN
| | | | - Keith C Bible
- Division of Medical Oncology, Mayo Clinic, Rochester, MN
| | | | - Sarika N Rao
- Division of Endocrinology, Mayo Clinic, Jacksonville, FL
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Jasim S, Jimenez C. Metastatic pheochromocytoma and paraganglioma: Management of endocrine manifestations, surgery and ablative procedures, and systemic therapies. Best Pract Res Clin Endocrinol Metab 2020; 34:101354. [PMID: 31685417 DOI: 10.1016/j.beem.2019.101354] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Metastatic pheochromocytomas and paragangliomas (MPPGs) are rare neuroendocrine tumors. Most patients present with advanced disease that is associated with manifestations of catecholamine release. Surgical resection of the primary tumor and ablative therapies of metastases-whenever possible-may improve clinical outcomes and, perhaps, lengthen the patient's overall survival. Significant steps in understanding the genetic alterations linked to MPPGs and scientific progress made on cancers that share a similar pathogenesis are leading to the recognition of potential systemic therapeutic options. Data derived from clinical trials evaluating targeted therapies such as tyrosine kinase inhibitors, radiopharmaceuticals, immunotherapy, and combinations of these will likely improve the outcomes of patients with advanced and progressive MPPGs. Exemplary of this success is the recent approval in the United States of the high-specific-activity iodine131 meta-iodine-benzylguanidine (MIBG) for patients with unresectable and progressive MPPGs that express the noradrenaline transporter. This review will discuss the therapeutic approaches for patients with MPPGs.
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Affiliation(s)
- Sina Jasim
- The Division of Endocrinology, Metabolism and Lipid Research, Campus box 8127, Washington University, School of Medicine, 660 S. Euclid Ave., St. Louis, Missouri 63110, USA
| | - Camilo Jimenez
- The Department of Endocrine Neoplasia and Hormonal Disorders at the University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1461, Houston, TX 77030, USA.
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Patel S, Owen D, Schmidt CR, Kirschner LS, Phay J, Shirley L, Dillhoff M, Brock P, Espinosa A, Shah MH, Konda B. Favorable and Durable Response to Pazopanib in Metastatic Refractory Paraganglioma. J Oncol Pract 2017; 13:840-842. [PMID: 28850312 DOI: 10.1200/jop.2017.024984] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Sandipkumar Patel
- The Ohio State University Comprehensive Cancer Center and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Dwight Owen
- The Ohio State University Comprehensive Cancer Center and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Carl R Schmidt
- The Ohio State University Comprehensive Cancer Center and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Lawrence S Kirschner
- The Ohio State University Comprehensive Cancer Center and The Ohio State University Wexner Medical Center, Columbus, OH
| | - John Phay
- The Ohio State University Comprehensive Cancer Center and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Lawrence Shirley
- The Ohio State University Comprehensive Cancer Center and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mary Dillhoff
- The Ohio State University Comprehensive Cancer Center and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Pamela Brock
- The Ohio State University Comprehensive Cancer Center and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Allan Espinosa
- The Ohio State University Comprehensive Cancer Center and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Manisha H Shah
- The Ohio State University Comprehensive Cancer Center and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Bhavana Konda
- The Ohio State University Comprehensive Cancer Center and The Ohio State University Wexner Medical Center, Columbus, OH
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Jasim S, Suman VJ, Jimenez C, Harris P, Sideras K, Burton JK, Worden FP, Auchus RJ, Bible KC. Phase II trial of pazopanib in advanced/progressive malignant pheochromocytoma and paraganglioma. Endocrine 2017; 57:220-225. [PMID: 28685225 DOI: 10.1007/s12020-017-1359-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/18/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Pheochromocytomas and paragangliomas (Pheo/PGL) are rare, vascular, sometimes malignant endocrine tumors. Case reports indicate the activity of vascular endothelium growth factor receptor-targeted kinase inhibitors in these cancers. OBJECTIVES To assess the antitumor activity and tolerability of pazopanib in progressive malignant Pheo/PGL. PATIENTS AND METHODS This multicenter Phase II trial (MC107C) enrolled individuals ≥18 years old with disease progression ≤ 6 months prior to registration, Eastern Cooperative Oncology Group PS 0-2, and measurable disease (response evaluation criteria in solid tumors 1.0). Pazopanib was administered in 28-day cycles, with the regimen ultimately being as follows: cycle 1: 400 mg daily on days 1-14, cycle 2: 800 mg daily on days 1-14, and then cycle 2 + : 800 mg daily on all days. RESULTS The study was halted due to poor accrual. Seven patients were enrolled (05/2011-11/2014). One patient withdrew consent prior to treatment, leaving six evaluable patients. Treatment was discontinued, due to the following reasons: disease progression (4); withdrawal (1); and grade 4 (Takotsubo) cardiomyopathy (1). The median number of cycles administered was 4 (range: 2-29, total: 49). Four patients had >1 dose reduction due to the following reasons: fatigue (1), abnormal liver tests (2), hypertension and (Takotsubo) cardiomyopathy (1), and headaches (1). Common severe (Common Terminology Criteria for Adverse Events v3.0 grades 3-5) toxicities were as follows: hypertension (3/6), (Takotsubo) cardiomyopathy (2/6), diarrhea (1/6), fatigue (1/6), headache (1/6), and hematuria (1/6). One confirmed partial response was observed in PGL (17%, duration 2.4 years); median progression-free survival and overall survival were 6.5 and 14.8 months, respectively. CONCLUSION Pazopanib has activity in Pheo/PGL requiring more study; optimal alpha- and beta-blockade are imperative pre-therapy in patients with secretory tumors, as risk of hypertension and cardiomyopathy are potentially life threatening.
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Affiliation(s)
- Sina Jasim
- Department of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Vera J Suman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Camilo Jimenez
- University of Texas, MD Anderson Cancer Center, 1155 Pressler Street, Houston, TX, 77030, USA
| | - Pamela Harris
- National Institute of Health (NIH/NCI), 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Kostandinos Sideras
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, NA-0621s, Gravendijkwal 230, Rotterdam, 3015 CE, Netherlands
| | - Jill K Burton
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Francis Paul Worden
- Division of Medical Oncology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Richard J Auchus
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine and Department of Pharmacology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Keith C Bible
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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